* Indicates A Field That Requires A Response Full Legal Name Last Name * First Name * Middle Name * Name Known by / or Nick Name   Street Address * City * State * Zip Code *   Phone * E-mail Address *   Place of employment * Work Phone *   Are you a ERC-Chester Recovery Alumni? * Yes No Sobriety Date What 12-step groups do you attend?   Have you ever been convicted of a felony? * Yes No If YES, dates and charges   Availability Day(s) * Sunday Monday Tuesday Wednesday Thursday Friday Saturday Any Day Time / Hours Areas of Volunteer Interest Emergency Contact Name * Emergency Contact's Phone *   Please provide 3 references. Reference #1 Name * Address City State Zip Phone *   Reference #2 Name * Address City State Zip Phone *   Reference #3 Name Address City State Zip Phone *   Please Read the Following Carefully Criminal Record History Release Form: The Empowerment Resurrection Center of Chester Volunteer Program requires volunteers, 18 years and older, to complete a Criminal Record History Release Form to protect our volunteers, clients, and staff. Note that at the anniversary date of volunteer status, an updated Criminal Release form must be signed for continued volunteer privileges.   By typing my FULL NAME and providing TODAY's DATE in the following spaces I state that I have read and hereby agree to the Criminal Record History Release provision as stated on this application form, should I be accepted as a ERC-Chester volunteer. And, that all the information that I have provided is true and accurate to the best of my knowledge. Full Applicant Name * Today's Date *   Security Code * Type the following letters and numbers as they appear into the empty box. Letters can be either upper or lowercase.... Click SUBMIT when you are satisfied with your responses. Click the Submit button only ONE time. After submitting, you will taken to our Successful Submission page, where you can continue to browse our site.